schildhauer2003 navicular fracture

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Technical Tricks
Temporary Bridge Plating of the Medial Column in Severe
Midfoot Injuries
Thomas A. Schildhauer, Sean E. Nork, and Bruce J. Sangeorzan
Department of Orthopaedics, Harborview Medical Center, University of Washington, Seattle, Washington
Summary: Severe crush injuries to the midfoot often involve
comminuted cuneiform or tarsal navicular fractures. Treatment
principles for the bony injury of the crushed midfoot include
maintenance of the medial column length and alignment, as
well as appropriate stable fixation after open or closed fracture
reductions. This is especially important because outcomes after
midfoot injuries are related to the stability of the medial lon-
gitudinal arch of the foot. Treatment options include closed
reduction and isolated K-wire fixation, limited open reduction
and internal fixation with K-wires, screw fixation directed from
the navicular to the cuneiforms, spanning external fixation be-
tween the talus and the first metatarsal, or combinations of
these techniques. Limited internal fixation combined with ex-
ternal fixation may be difficult or impossible in comminuted
fractures secondary to the small size and large number of bony
fragments. Also, the external fixator is a potential source of pin
tract infections. We propose a temporary internal bridge plating
technique of the medial column of the foot using an 8- to
10-hole, 2.7-mm reconstruction plate between the talar neck
and the first metatarsal, which may provide adequate temporary
internal stabilization until bony healing occurs.
Key Words: midfoot crush injury, plate osteosynthesis, cho-
part joint fracture–dislocation, tarsal navicular fracture, cunei-
form fracture
Crush injuries to the midfoot typically involve both
columns of the foot.1 The lateral column consists of the
calcaneus, the cuboid, and the fourth and fifth metatar-
sals. The medial column is comprised of the talus, the
tarsal navicular, the three cuneiforms, and the first, sec-
ond, and third metatarsals. Whereas the cuboid has a
central role in maintaining the integrity of the lateral
column, the tarsal navicular is the keystone for the me-
dial column. Therefore, anatomic reduction and adequate
internal fixation of these bones are of particular impor-
tance.
Midfoot crush injuries are invariably associated with
significant soft tissue disruption, making soft tissue sta-
bilization a primary goal. Treatment principles of the
osseus injury may include the following: 1) maintaining
appropriate lateral and medial column length; 2) main-
taining the appropriate relationship between the forefoot
and hindfoot to ensure a plantigrade foot; 3) preserving
motion at the talonavicular joint and the cuboid–
metatarsal articulation; and 4) using stable internal fixa-
tion to maintain anatomical reductions or primary ar-
throdeses.2 Maintaining relative column length can prove
challenging when fractures are comminuted, however. A
shortened medial column tends to produce a cavus foot,
whereas a shortened lateral column may cause a planus
foot.
Crush injuries to the medial column of the foot fre-
quently present with type 3 tarsal navicular fractures,
which are characterized by a comminuted fracture in the
sagittal plane of the navicular body with the lateral fore-
foot displacement.3 Adequate internal stabilization of
these combined navicular fractures and multifragmented
cuneiform fractures may be problematic. After recon-
struction of the length and alignment of the medial col-
umn, direct plate or screw fixation of the tarsal navicular
may be impossible because of the small size and large
number of bony fragments. Bridging external fixation
between the first metatarsal and the talus is typically
accomplished with two- to three-point fixation and,
therefore, may be insufficient for stable fracture fixation.
In addition, external fixation is a potential source of pin
tract infections. Medial column K-wire fixation remains
a possible treatment option but may not provide suffi-
cient internal fixation to hold the reduction over time,
making alternative techniques desirable. For these situ-
ations, we propose a temporary internal bridge plating
Accepted June 4, 2002.
The authors have received nothing of value.
The devices that are the subject of this manuscript are FDA ap-
proved.
Corresponding author: Dr. Thomas A. Schildhauer, Chirurgische
Klinik und Poliklinik, BG-Kliniken Bergmannsheil, Ruhr-Universität
Bochum, Bürkle-de-la-Camp-Platz 1, Bochum D-44789, Germany.
E-mail: thomas.a.schildhauer@ruhr-uni-bochum.de.
Journal of Orthopaedic Trauma
Vol. 17, No. 7, pp. 513–520
© 2003 Lippincott Williams & Wilkins, Inc., Philadelphia
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technique of the medial column of the foot, which can
provide adequate temporary internal stabilization until
bony fracture healing occurs.
OPERATIVE TECHNIQUE
After appropriate care of the soft tissues and higher
priority injuries, the patient is positioned supine on the
operating table. A dorsomedial approach to the foot is
performed with an incision starting proximally at the
ankle joint and medial to the tibialis anterior tendon,
continuing laterally over the tibialis anterior insertion at
the medial cuneiform, and extending distally to the mid-
portion of the dorsomedial first metatarsal. The incision
is carried carefully through the subcutaneous tissues, pre-
serving the branches of the saphenous and superficial
peroneal nerves (a in Fig. 1). Venous branches of the
saphenous vein (b in Fig. 1B) are ligated or coagulated.
The tibialis anterior and extensor hallucis longus tendons
(c and in Fig. 1) are identified and protected throughout
the procedure by using blunt retractors. The extensor
retinaculum (e in Fig. 1) may be transected if bridge
plating onto the talar neck is planned. Dissection is con-
tinued onto the dorsal aspects of the fractured tarsal na-
vicular and cuneiforms (f, g, and i in Fig. 1). Reduction
of larger bony fragments is performed and temporarily
stabilized with K-wires. A medial external fixator may
be helpful for fracture reduction and reconstitution of the
overall alignment of the medial column. In these cases, a
temporary two-point external fixator is placed between
the distal aspect of the first metatarsal (h in Fig. 1) and
the tuber calcanei or the talar neck. In cases with addi-
tional Lisfranc’s joint injuries, screw osteosynthesis of
those injuries is performed. For maintenance of the over-
all medial column alignment and length, an 8- to 10-hole,
2.7-mm reconstruction plate is placed over the medial
aspect of the medial column of the foot. If the tarsal
navicular bone is injured, the bridge plate may be ex-
tended onto the medial aspect of the talar neck (l in Figs.
1 and 2). In these cases, the tibialis anterior tendon is
retracted medially (c in Fig. 2) and the plate is applied
beneath the tendon. The medial column is stabilized with
two 2.7-mm screws in the talar neck and two similar
screws into the first metatarsal (h in Fig. 2). Placement of
the screws into the talar neck often requires lateral re-
traction of the tibialis anterior tendon. If there is com-
minution of the navicular, slight distraction is introduced
at the talonavicular joint through the plate. Because this
is the critical joint of the midfoot, pressure across that
joint with comminuted joint surfaces should be avoided.
Additional screws can be placed through the plate into
the tarsal navicular or medial cuneiform. Screws into the
medial cuneiform should extend into the middle and lat-
eral cuneiform, as well as into the base of the second and
third metatarsal bone to gain higher intrinsic stability of
the injured midfoot (Fig. 2). If the tarsal navicular is
intact, proximal dissection onto the talus is unnecessary,
and the plate can be positioned from the navicular to the
first metatarsal. Bridge platefixation is again achieved
with two screws proximally into the tarsal navicular and
distally into the first metatarsal with additional screw
fixation to the medial cuneiform. In certain midfoot crush
FIGURE 1. Dorsomedial approach to
the medial column of the foot. A, Dis-
section for bridge plating between the
tarsal navicular and first metatarsal
bone. B, Dissection for bridge plating
between talar neck and first metatar-
sal bone. The tibialis anterior tendon
has to be moved laterally for place-
ment of screws in the proximal end of
the plate. a: superficial peroneal
nerve branches; b: saphenous vein;
c: tibialis anterior tendon; d: extensor
hallucis longus tendon; e: extensor
retinaculum; f: tarsal navicular; g: me-
dial cuneiform; h: first metatarsal
bone; i: middle cuneiform; k: second
metatarsal bone; l: talus; m: dorsalis
pedis artery and vein as well as deep
peroneal nerve; q: musculus extensor
hallucis brevis.
Schildhauer et al514
J Orthop Trauma, Vol. 17, No. 7, 2003
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injuries combined with a Lisfranc’s joint fracture–
dislocation, bridge plating can alternatively be placed
over the second metatarsal, middle cuneiform, and tarsal
navicular to avoid interference with screw fixation of the
first ray. Two-layered wound closure is performed after
repair of the joint capsules and extensor retinaculum, and
the medial external fixator can be removed. Lateral col-
umn reconstruction can then be performed, if indicated.
The postoperative management varies with the sever-
ity of the injuries. However, a staged removal of the
medial column bridge plate crossing the talonavicular
joint is planned approximately 3 months postoperatively.
In general, the patient is kept toe-touch weight bearing
for 6–8 weeks. Weight bearing is advanced according to
clinical and radiographic assessment of the healing. The
bridge plate can then be removed, followed by advance-
ment of weight bearing and range of motion exercises. In
cases that required extension of the medial column
bridge plate onto the talar neck, the plate can initially be
shortened in situ over the talonavicular joint, leaving the
rest of the plate to allow for ongoing stabilization of the
midfoot. Plates bridging between the tarsal navicular and
the first metatarsal can be left in place while full weight
bearing is performed.
PATIENTS
Review of our database revealed seven patients treated
between 1998 and 2000 at Harborview Medical Center, a
level I trauma center, with bridge plating of the medial
column of the foot resulting from acute midfoot trauma.
The average age was 39 years (range 27–56 years), and
the mechanisms of injury included motor vehicle acci-
dents, falls, and a direct crush injury. The latter resulted
in an open fracture–dislocation. In three patients, the
talonavicular joint was bridged. The plates were ex-
tended distally to the medial cuneiform in two patients
and to the first metatarsal in the other patient. The talo-
navicular spanning hardware was removed at 4 and 8
months. In the remaining patients, bridge plating was
performed between the tarsal navicular and the first
metatarsal bone. All injuries healed without loss of re-
duction. The overall length and alignment of the medial
column of the foot were maintained. No secondary
wound problem occurred with these plate fixations.
Three patients underwent removal of all hardware. Two
patients described local soft tissue irritation over the im-
plants when wearing shoes. No other complications–-ie,
infection or implant loosening–-were observed.
CASE REPORT
A 27-year-old male patient fell approximately 5 m off
some scaffolding while working. He sustained a crush
injury to his left foot (Fig. 3) and an associated left tibial
plateau fracture. The closed crush injury to his foot in-
cluded a left lateral midtarsal (Chopart’s) joint fracture–
dislocation (77-D13) with a multifragmentary articular
navicular fracture (74-C1.2), a partial articular sagittal
split-depression fracture of the cuboid (76-B1.3), an ex-
traarticular split fracture of the middle [75(2)-A2.1] and
lateral [75(3)-A2.1] cuneiforms, and a divergent disrup-
tion of the tarsometatarsal joint (80-D56).24 On the day
of injury, the midfoot was reduced closed, and spanning
medial and lateral external fixators were applied between
the tuber calcanei and first metatarsal, and tuber calcanei
and base of the fourth and fifth metatarsals, respectively.
After soft tissue swelling decreased, open reduction and
internal stabilization was performed on the 7th day
postinjury (Fig. 4). The medial column was stabilized
with a 10-hole, 2.7-mm reconstruction plate extending
between the talar neck and first metatarsal. This was
combined with an interfragmentary 2.7-mm screw fixa-
tion of the navicular. The cuboid fracture was treated
with open reduction, bone grafting, and internal fixa-
tion using a 2.0-mm T-plate. The articulations between
the cuboid and the fourth and fifth metatarsals were
temporarily stabilized with two 2.0-mm K-wires. Post-
operative management included toe-touch weight bear-
ing for 3 months and K-wire removal after 6 weeks
FIGURE 2. Stabilization of the medial column between the talar
neck (l) and first metatarsal bone (h) using a 10-hole, 2.7-mm
reconstruction plate. Screws are extending into the lateral cune-
iform (o) and base of the second and third (n) metatarsal bone for
higher intrinsic stability of the midfoot fixation. p: calcaneus. See
also Figure 1 legend.
Bridge Plating for Midfoot Injuries 515
J Orthop Trauma, Vol. 17, No. 7, 2003
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postoperatively. Four months postoperatively, the medial
column bridge plate was shortened proximally between
the talus and tarsal navicular to allow for restoration of
motion in the talonavicular joint. The shortened plate
was left in place for ongoing stabilization of the midfoot.
The fracture–dislocations of his midfoot healed unevent-
fully, and on his 6-month follow-up examination, he pre-
sented with full weight bearing while using a cane (Fig.
5). One year postoperatively, all hardware was removed
because of soft tissue irritation at the dorsum of his foot
when wearing shoes (Fig. 6).
DISCUSSION
Crush injuries to the medial column of the midfoot
typically involve fractures and fracture–dislocations to
the tarsal navicular. They occur rarely and have been
presented primarily as case reports in the literature.4–16
Larger series are available with inconsistent treatment
recommendations.1,3,17–20 Although recent series agree
that some form of reduction is necessary in these injuries,
recommendations for stabilization vary. Predominantly,
K-wire fixation is suggested if the reduction is performed
early and if the navicular fragments are not too commi-
nuted.1,18,20,21 Sangeorzan et al3 recommended lag screw
fixation across the navicular fragments if these fragments
are large enough. In comminuted fractures and crush
injuries, Main and Jowett20 performed closed or open
reduction with plaster treatment, or debridement and
bone excision. Sangeorzan et al3 used a spanning exter-
nal fixator between the talus and first metatarsal com-
bined with screws directed from the navicular into the
second and third cuneiforms or the cuboid. In one of their
patients, temporary smooth pin fixation between the na-
vicular and talus was performed. Day17 suggested pri-
mary triple arthrodesis combined with arthrodesis of the
cuneonavicular joints, which is in contrast to recent re-
ports.2,20
Foot injuries have been shown to significantly impact
on the functional outcome of polytraumatized patients.22
Furthermore, Main and Jowett20 demonstrated that out-
come is related to the stability of the medial longitudinal
arch of the foot. However, this may not be accomplished
with K-wire fixation or screw osteosynthesis in injuries
with significant comminution and an associated midfoot
crush injury.Although a medial spanning external fixator
FIGURE 3. Preoperative plain radiographs in anteroposterior (A) and lateral (B) views demonstrating a crush injury to the left foot from
a 5-m fall. The injury included a lateral midtarsal (Chopart’s) joint fracture–dislocation with a multifragmentary articular navicular fracture,
a partial articular sagittal split-depression fracture of the cuboid, an extraarticular split fracture of the middle and lateral cuneiforms, and
a divergent disruption of the tarsometatarsal joint.
Schildhauer et al516
J Orthop Trauma, Vol. 17, No. 7, 2003
may assist in medial column length maintenance, this
option does not provide direct stability to the injured
midfoot. In addition, long-term application of an external
fixator risks infection and pin loosening with resultant
loss of reduction. A bridge plate across the medial col-
umn of the foot allows stable fixation of the midfoot
reduction and minimizes secondary loss of reduction de-
spite severe comminution.
The intercuneiform joints, the naviculocuneiform
joint, and the medial three tarsometatarsal joints have
little or no essential movement in the normal foot and
can primarily be arthrodesed with minimal functional
loss.2 However, important movements in the foot occur
at the talonavicular and calcaneocuboid joint, as well as
the articulation between the cuboid and the fourth and
fifth metatarsal bases. Fusion of these articulations is
not well tolerated.2 Bridge plating of the midfoot be-
tween the first metatarsal and talus should therefore be
only a temporary internal fixation until fracture healing
has occurred. Bridge plating is not meant as a fusion
of the whole medial column of the foot. After 4–9
months, the plate between the talus and tarsal navicular
should be removed to allow restoration of the function in
the transverse tarsal and subtalar joints, as fusion of the
talonavicular joint significantly decreases calcaneocu-
boid joint motion and essentially eliminates subtalar
joint motion.23 This can be accomplished either by com-
plete hardware removal or plate exchange to exclude the
FIGURE 4. Postoperative anteropos-
terior (A) oblique (B) and lateral (C)
radiographs demonstrating the op-
erative stabilization. The medial col-
umn was stabilized with a 10-hole,
2.7-mm reconstruction plate between
the talar neck and first metatarsal
combined with an interfragmentary
2.7-mm screw fixation of the navicu-
lar.
Bridge Plating for Midfoot Injuries 517
J Orthop Trauma, Vol. 17, No. 7, 2003
talonavicular joint. The latter allows for further lasting
stabilization of the rest of the medial column of the mid-
foot.
Severe crush injuries to the foot are typically com-
bined with considerable open or closed soft tissue inju-
ries. This often precludes early open reduction and in-
ternal fixation. In these situations, a closed reduction and
application of an external fixator between the talus and
the first metatarsal may be performed: 1) to restore the
length and alignment of the medial column; 2) to reduce
internal pressure on the soft tissue caused by dislocated
bony fragments; and 3) to facilitate later internal fixation.
After foot swelling and associated soft tissue injuries are
stabilized, the external fixator can easily be exchanged to
an internal bridge plate with its associated improved
midfoot reduction and stabilization.
Bridge plating of the medial column of the foot is
indicated in severely comminuted midfoot fracture–
dislocations and was performed successfully in seven of
our patients. The spanning plate can bridge the medial
column from the talar neck to the first metatarsal, but
early plate removal at the talonavicular joint is recom-
mended to allow for restoration of motion at the midtar-
sal (Chopart’s) joint. Care has to be taken that the tibialis
anterior tendon and its insertion are not disrupted or en-
dangered while bridge plating to the talar neck is per-
formed. The use of a low-profile 2.7-mm reconstruction
plate may help prevent painful prominence under the thin
FIGURE 5. Four months postopera-
tively, the medial column bridge plate
was shortened proximally between
the talus and tarsal navicular to allow
for restoration of motion in the talona-
vicular joint. The shortened plate was
left in place for ongoing stabilization
of the midfoot. The radiographs dem-
onstrate anteroposterior (A) oblique
(B) and lateral (C) follow-up films 6
months postoperatively with the pa-
tient fully weight bearing.
Schildhauer et al518
J Orthop Trauma, Vol. 17, No. 7, 2003
soft tissue coverage at the dorsomedial foot; otherwise,
hardware removal is recommended.
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Bridge Plating for Midfoot Injuries 519
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